In 2017, hospital administrators at Marietta, GA-based Wellstar Health System wanted to know more about ethics consultation volume.
“They were particularly interested in learning how many consults our institution should have,” says Jason Lesandrini, FACHE, LPEC, HEC-C, assistant vice president of ethics, advance care planning, and spiritual health.
The goal was to create a higher-volume ethics service. Hospital leaders wanted to know what staffing model ethics should be using to meet the needs of providers, patients, families, and the community.
The questions sounded simple enough, but were quite challenging to answer. “Currently, there is no standard method to assess how many consults should be performed,” Lesandrini explains.
To learn more about the issue, researchers reviewed the literature. They analyzed 19 studies on volume of ethics consult services that were requested from 2000 to 2017, institutional surveys on consult volume, and statistical analyses that estimated the volume of ethics consult services.1 After gathering some additional data from the study authors, the researchers concluded the inconsistent way ethics consult volume was reported was problematic. This made estimates of growth over time inaccurate.
It turned out that many factors were omitted from the volume predictions. For instance, types of physician services that were available (or not) at a given hospital or changes in the number of hospital beds were not factored in.
The researchers created a methodology to allow these and other factors to be weighed. This means ethics services can accurately estimate how many consults they should be performing. “We were surprised to answer a question that we thought was unanswerable,” Lesandrini reports.
The methodology uses published research, survey responses, and many other factors (including hospital admissions and bed size) to predict low-, moderate-, and high-consult volume. Some key findings:
• Institutional variables (such as religious affiliation) and hospital settings (including the presence or absence of a palliative care or pediatric unit) did not affect ethics consultation volume. The researchers viewed this finding with skepticism. It is counterintuitive that the presence or absence of these units do not affect ethics consult volume, says Thomas V. Cunningham, PhD, MA, MS, a co-author of the study.
More likely, the finding reveals the limitations of data collection currently, and the fact that a small sample of mostly homogenous hospitals was used. “Our methods of measuring ethics consultation service activity are too crude to show that these other variables impact consult service activities,” says Cunningham, bioethics director of Kaiser Permanente West Los Angeles Medical Center.
• Ethics consultation services using an individual ethicist or sole consultant model recorded higher consult volumes than committees, small teams, and hybrid models. “We expected the data to show this. It is consistent with anecdotes that are widespread in the field,” says Cunningham, adding that with a larger sample size, the effect probably would be even more pronounced.
Institutions usually see a large spike in volume when they invest in an individual ethicist to cover a hospital ethics consult service. In light of this, says Lesandrini, “administrators thinking about expanding capacity should explore allocating resources and funding an individual ethicist.”
There is no standardized way to report data on ethics consultation. Therefore, there is no reliable way to analyze, interpret, or estimate ethics consult volume across institutions. “Creating a consistent metric that assesses volume will demonstrate the value, sustainability, and impact of offering healthcare ethics consultation services,” Lesandrini offers.
Many ethics services have been measuring volume for a long time. “But volume isn’t the whole story,” Cunningham notes.
Practices vary in terms of how many people handle ethics consults, the size of ethics committees, and whether there are full-time ethicists. A hospital might report many ethics consults or only a few, but that says nothing about the quality of those consults. “If consults are really well done, and are exactly the cases that need to be heard in the hospital, it’s likely a high-quality service,” Cunningham reports.
Service leaders may want to move from low-volume to moderate-volume, but they do not know how to get there. With more nuanced data on the number of consults, ethicists can move forward with confidence. “It will give you a better handle on where you rank compared to other hospitals and understanding where you want to go,” Cunningham suggests.
Some ethics consult services are not even measuring their volume at all. Others measure, but inconsistently. “The big difference between ethics and other clinical areas is that in ethics, the data [are not] being collected unless the ethicist collects it,” Cunningham explains.
Some EMRs provide a way to track the number of consults. Ethicists can collaborate with the quality department to capture these data. “But once you count them, now you have to analyze them. We can compare volume, but it hides so many things because systems are so different,” Cunningham cautions.
An ethics consult service may report much lower volume compared to a nearby hospital that serves a different, more complex patient population. On the other hand, low volume could be a sign that clinicians are unaware of the ethics service or do not consider it helpful.
Changes in volume also are difficult to interpret and require some more context to understand what is behind it. “As for whether volume fluctuations are a good or bad thing, that really requires other information to answer that question,” Cunningham says.
In hospitals without an established ethics consultation service, a “good” reason for increased volume would be funding a full-time clinical ethicist. “That should lead to significantly more volume,” Cunningham says.
If the institution already has an established ethics consultation service in place, Cunningham says these would be some “good” reasons for more volume:
- The institution offers more services to cover care that was not provided (e.g., bariatric surgery, transgender surgery, a higher-level neonatal ICU, more ICU beds);
- The institution provides additional administrative support to the ethicist, which allows him or her to round more — and putting more attention on ethical issues;
- There are changes in the federal or state legal or regulatory landscape in ways that affect medical ethics (e.g., laws that allow clinical ethicists to support physicians in making decisions for unrepresented patients, legalize physician aid-in-dying, or restrict the way DNR orders can be enacted in the hospital).
More context on volume “is essential for strategic planning within the ethics committee and for comparison,” Cunningham stresses.
At the institutional level, ethicists need good data to compare the work, over time, of multiple ethicists in the hospital, and to compare the work of ethicists who are working across multiple hospitals. On the regional level, different hospitals need to compare ethics services in a meaningful way. “If we had data across facilities, and knew more about the kind of cases they were seeing, we could have a powerful data set to be able to say what’s normal for an ethics consult service in a particular setting,” Cunningham says.
- Glover AC, Cunningham TV, Sterling EW, Lesandrini J. How much volume should healthcare ethics consult services have? J Clin Ethics 2020;31:158-172.